07 May 2025
GIRFT report found some trusts were manipulating more displaced forearm fractures in the emergency department rather than in theatre. If more trusts adopted this, more conservative, approach to fracture management a significant amount of theatre time could be saved1.
Many uncomplicated paediatric clavicle fractures can be managed without x-rays2, and this is also considered true for toe fractures.
British Society for Children’s Orthopaedic Surgery (BSCOS) guidance suggests that no referral/follow up is required for many fractures of the clavicle, elbow, wrist and toes where there is no or minimal displacement3.
So, there is interest in understanding what the potential reductions in activity could be if trusts were to implement more conservative management of paediatric fractures.
Calculate the incidence of fractures recorded in emergency care in England, specifically:
forearm
elbow
clavicle
tibia/fibula
toe
Understand the trends in fracture management over time.
Investigate the variation in management of these fracture types between trusts, and therefore opportunity for activity savings if there was more widespread conservative management.
The study population included those:
- who had attended an emergency department/urgent treatment centre in England between April 2019 and March 2024 AND
- were aged 16 and under AND
- had a SNOMED code for closed fractures of toe, clavicle, elbow, forearm or tibia/fibula recorded
Emergency care dataset (ECDS) linked with records in the Outpatient (OPA) and Admitted Patient Care Episode (APCE) datasets.
The coding of fractures is not sufficiently detailed and reliable to determine specific fracture types, and thus what would be the appropriate treatment at an individual patient level. However, we could calculate the proportion of children with each fracture type that:
Forearm fractures are the most common followed by elbow fractures.
SNOMED description | Number | Percentage | |
|---|---|---|---|
Closed fracture of radius (disorder) | Forearm | 48,043 | 35.2 |
Elbow fracture - closed (disorder) | Elbow | 18,613 | 13.6 |
Closed fracture of radius AND ulna (disorder) | Forearm | 17,498 | 12.8 |
Closed fracture of clavicle | Clavicle | 15,259 | 11.2 |
Closed fracture of phalanx of foot (disorder) | Toe | 15,232 | 11.1 |
Closed fracture of tibia (disorder) | Tibia/Fibula | 8,549 | 6.3 |
Closed fracture of ulna (disorder) | Forearm | 4,347 | 3.2 |
Closed supracondylar fracture of humerus (disorder) | Elbow | 3,394 | 2.5 |
Closed fracture of fibula (disorder) | Tibia/Fibula | 3,278 | 2.4 |
Closed fracture of tibia AND fibula (disorder) | Tibia/Fibula | 2,145 | 1.6 |
Closed Monteggia's fracture (disorder) | Elbow | 108 | 0.1 |
Closed Galeazzi fracture (disorder) | Forearm | 65 | 0.0 |
Closed fracture of distal end of radius (disorder) | Forearm | 23 | 0.0 |
Only showing those fracture types recorded 10 or more times
The majority of fractures are recorded under just a few snomed codes.
‘Closed fracture of radius (disorder)’ will likely include some proximal radius fractures that would be more accurately classified at elbow fractures.
Fractures of great toe were excluded, as these should be followed up. However these codes are not really used, suggesting great toe fractures may be coded as ‘Closed fracture of phalanx of foot (disorder)’ and thus included within our dataset.
Percentage of diagnoses in emergency care that are for our fractures of interest in those aged 16.
Percentage of emergency care attendances without a diagnosis code for those aged 16 or under.
There is considerable variability between providers in the percentage emergency care attendances where a fracture is recorded, even when accounting for the different rates of recording diagnoses seen between trusts.
These differences could be due to:
Alternative provision locally, e.g. in some areas there is independent urgent care provision available.
Regional differences in fracture rate, which may be related to levels of physical activity, visitors from out of area and the demographic of the area.
Fracture diagnoses being disproportionately recorded by trusts.
ICB | Clavicle | Elbow | Forearm | Tibia/Fibula | Toe | Total | % of ED attendances |
|---|---|---|---|---|---|---|---|
NHS Cornwall and the Isles of Scilly ICB | 220 | 365 | 1,136 | 177 | 262 | 2,159 | 1 |
NHS Herefordshire and Worcestershire ICB | 201 | 308 | 1,016 | 142 | 269 | 1,934 | 22 |
NHS Shropshire, Telford and Wrekin ICB | 215 | 292 | 971 | 139 | 230 | 1,847 | 24 |
NHS Gloucestershire ICB | 222 | 186 | 1,004 | 183 | 205 | 1,800 | 37 |
NHS Derby and Derbyshire ICB | 185 | 256 | 905 | 169 | 232 | 1,747 | 13 |
NHS Somerset ICB | 195 | 280 | 925 | 150 | 190 | 1,740 | 18 |
NHS Dorset ICB | 188 | 280 | 857 | 145 | 194 | 1,664 | 26 |
NHS South Yorkshire ICB | 192 | 305 | 803 | 169 | 193 | 1,662 | 18 |
NHS Norfolk and Waveney ICB | 198 | 281 | 842 | 167 | 165 | 1,653 | 8 |
NHS Devon ICB | 188 | 262 | 871 | 163 | 150 | 1,634 | 23 |
NHS Black Country ICB | 164 | 304 | 818 | 148 | 144 | 1,578 | 42 |
NHS Sussex ICB | 162 | 241 | 825 | 128 | 171 | 1,528 | 16 |
NHS North East and North Cumbria ICB | 146 | 232 | 748 | 148 | 186 | 1,460 | 26 |
NHS Humber and North Yorkshire ICB | 187 | 213 | 727 | 136 | 162 | 1,425 | 18 |
NHS Lincolnshire ICB | 146 | 214 | 736 | 134 | 187 | 1,417 | 6 |
NHS Coventry and Warwickshire ICB | 174 | 189 | 717 | 146 | 149 | 1,375 | 16 |
NHS Bedfordshire, Luton and Milton Keynes ICB | 132 | 246 | 688 | 110 | 146 | 1,322 | 22 |
NHS Greater Manchester ICB | 140 | 196 | 708 | 114 | 164 | 1,322 | 32 |
NHS Mid and South Essex ICB | 138 | 215 | 660 | 163 | 137 | 1,312 | 6 |
NHS Cheshire and Merseyside ICB | 150 | 221 | 661 | 139 | 141 | 1,311 | 31 |
NHS Hampshire and Isle of Wight ICB | 134 | 231 | 638 | 139 | 125 | 1,267 | 19 |
NHS West Yorkshire ICB | 156 | 200 | 621 | 132 | 133 | 1,243 | 23 |
NHS Birmingham and Solihull ICB | 127 | 236 | 603 | 123 | 142 | 1,232 | 18 |
NHS Bristol, North Somerset and South Gloucestershire ICB | 125 | 226 | 589 | 177 | 91 | 1,208 | 7 |
NHS Nottingham and Nottinghamshire ICB | 131 | 216 | 597 | 150 | 114 | 1,208 | 13 |
NHS Northamptonshire ICB | 144 | 202 | 578 | 97 | 118 | 1,139 | 13 |
NHS Bath and North East Somerset, Swindon and Wiltshire ICB | 145 | 191 | 571 | 116 | 94 | 1,117 | 24 |
NHS South West London ICB | 130 | 111 | 569 | 149 | 141 | 1,101 | 39 |
NHS Cambridgeshire and Peterborough ICB | 146 | 179 | 550 | 99 | 120 | 1,094 | 45 |
NHS Suffolk and North East Essex ICB | 145 | 157 | 523 | 106 | 129 | 1,060 | 27 |
NHS Lancashire and South Cumbria ICB | 122 | 170 | 530 | 124 | 107 | 1,052 | 31 |
NHS Hertfordshire and West Essex ICB | 110 | 150 | 506 | 100 | 113 | 980 | 22 |
NHS Surrey Heartlands ICB | 130 | 162 | 460 | 102 | 115 | 970 | 31 |
NHS Leicester, Leicestershire and Rutland ICB | 99 | 168 | 446 | 128 | 94 | 934 | 2 |
NHS Staffordshire and Stoke-on-Trent ICB | 87 | 121 | 503 | 88 | 125 | 923 | 12 |
NHS North Central London ICB | 92 | 135 | 438 | 107 | 92 | 864 | 34 |
NHS Kent and Medway ICB | 85 | 104 | 440 | 63 | 109 | 801 | 48 |
NHS North West London ICB | 82 | 132 | 393 | 88 | 74 | 770 | 38 |
NHS Buckinghamshire, Oxfordshire and Berkshire West ICB | 84 | 116 | 356 | 78 | 55 | 689 | 39 |
NHS Frimley ICB | 70 | 118 | 327 | 77 | 46 | 639 | 35 |
NHS South East London ICB | 62 | 103 | 293 | 72 | 69 | 598 | 23 |
NHS North East London ICB | 59 | 121 | 276 | 80 | 47 | 584 | 33 |
Incidence rates appear to vary by ICB area, but lower rates in some area may be the result of some trusts in those areas not reliably recording diagnoses codes for emergency care attendances.
Trend towards a reduction in the number upper limb fractures where a follow-up appointment is given.
As a result of the COVID-19 pandemic the proportion of follow up appointments conducted face-to-face has fallen significantly.
Odds Ratio | Confidence Intervals | P value | |
|---|---|---|---|
(Intercept) | 2.20 | 2.15 to 2.25 | <0.001* |
Sex | |||
Female | 1.00 | Reference | |
Male | 1.12 | 1.11 to 1.13 | <0.001* |
Age | |||
5-10 yrs | 1.00 | Reference | |
0-4 yrs | 0.96 | 0.94 to 0.97 | <0.001* |
11-16 yrs | 1.15 | 1.13 to 1.16 | <0.001* |
Ethnicity | |||
White | 1.00 | Reference | |
Asian or Asian British | 1.05 | 1.03 to 1.08 | <0.001* |
Black or Black British | 1.14 | 1.1 to 1.19 | <0.001* |
Mixed | 1.01 | 0.98 to 1.05 | 0.34 |
Other Ethnic Groups | 1.00 | 0.97 to 1.04 | 0.86 |
Missing/Unknown | 0.97 | 0.95 to 0.98 | <0.001* |
IMD Quintiles | |||
1- Most deprived | 1.00 | Reference | |
2 | 1.08 | 1.07 to 1.1 | <0.001* |
3 | 1.03 | 1.01 to 1.04 | <0.001* |
4 | 1.05 | 1.04 to 1.07 | <0.001* |
5- Least deprived | 1.08 | 1.06 to 1.1 | <0.001* |
Department type | |||
Major Emergency Department | 1.00 | Reference | |
Urgent Treatment Centre/Walk in centre | 0.96 | 0.95 to 0.98 | <0.001* |
Day of the week | |||
Week | 1.00 | Reference | |
Weekend | 1.06 | 1.05 to 1.08 | <0.001* |
Time of day | |||
Day 7am-7pm | 1.00 | Reference | |
Night 7pm to 7am | 1.12 | 1.1 to 1.13 | <0.001* |
Time of year | |||
Autumn | 1.00 | Reference | |
Winter | 0.94 | 0.93 to 0.96 | <0.001* |
Spring | 0.95 | 0.94 to 0.97 | <0.001* |
Summer | 0.99 | 0.97 to 1 | 0.06 |
Year | |||
2019/20 | 1.00 | Reference | |
2020/21 | 0.85 | 0.83 to 0.86 | <0.001* |
2021/22 | 0.79 | 0.77 to 0.8 | <0.001* |
2022/23 | 0.72 | 0.71 to 0.73 | <0.001* |
2023/24 | 0.72 | 0.71 to 0.73 | <0.001* |
Fracture type | |||
Clavicle | 0.79 | 0.78 to 0.8 | <0.001* |
Forearm | 1.00 | Reference | |
Elbow | 2.47 | 2.43 to 2.52 | <0.001* |
Tibia/Fibula | 2.09 | 2.05 to 2.14 | <0.001* |
Toe | 0.37 | 0.36 to 0.37 | <0.001* |
Children are more likely to be given a follow-up appointment if they are
male
11-16 yrs old
from an asian or black background
living in a less deprived area
They are also more likely to have a follow-up appointment if they attended
an emergency department
on a weekend
at nighttime
Those attending in more recent years were less likely to have a follow-up appointment, further indicating there has been a move towards fewer follow-up appointments.
The proportion of forearm fractures manipulated in the emergency department has increased and the proportion manipulated in theatre has decreased.
For forearm fractures currently over half of all manipulations are performed in the emergency department.
The total number of manipulations for forearm fractures has reduced.
Odds Ratio | Confidence Intervals | P value | |
|---|---|---|---|
(Intercept) | 5.87 | 5.29 to 6.52 | <0.001* |
Sex | |||
Female | 1.00 | Reference | |
Male | 0.93 | 0.88 to 0.99 | 0.01* |
Age | |||
5-10 yrs | 1.00 | Reference | |
0-4 yrs | 1.62 | 1.48 to 1.77 | <0.001* |
11-16 yrs | 0.51 | 0.48 to 0.54 | <0.001* |
Ethnicity | |||
White | 1.00 | Reference | |
Asian or Asian British | 0.81 | 0.73 to 0.91 | <0.001* |
Black or Black British | 0.49 | 0.41 to 0.59 | <0.001* |
Mixed | 0.69 | 0.6 to 0.8 | <0.001* |
Other Ethnic Groups | 0.54 | 0.46 to 0.62 | <0.001* |
Missing/Unknown | 0.85 | 0.78 to 0.93 | <0.001* |
IMD Quintiles | |||
1- Most deprived | 1.00 | Reference | |
2 | 0.76 | 0.7 to 0.82 | <0.001* |
3 | 0.71 | 0.66 to 0.77 | <0.001* |
4 | 0.68 | 0.63 to 0.74 | <0.001* |
5- Least deprived | 0.62 | 0.57 to 0.67 | <0.001* |
Department type | |||
Major Emergency Department | 1.00 | Reference | |
Urgent Treatment Centre/Walk in centre | 5.12 | 4.58 to 5.74 | <0.001* |
Day of the week | |||
Week | 1.00 | Reference | |
Weekend | 1.09 | 1.03 to 1.15 | <0.001* |
Time of day | |||
Day 7am-7pm | 1.00 | Reference | |
Night 7pm to 7am | 1.12 | 1.04 to 1.2 | <0.001* |
Time of year | |||
Autumn | 1.00 | Reference | |
Winter | 0.87 | 0.8 to 0.95 | <0.001* |
Spring | 1.06 | 0.99 to 1.14 | 0.09 |
Summer | 1.17 | 1.09 to 1.25 | <0.001* |
Year | |||
2019/20 | 1.00 | Reference | |
2020/21 | 0.43 | 0.4 to 0.47 | <0.001* |
2021/22 | 0.41 | 0.38 to 0.45 | <0.001* |
2022/23 | 0.28 | 0.26 to 0.3 | <0.001* |
2023/24 | 0.20 | 0.18 to 0.22 | <0.001* |
Children are more likely to have a fracture manipulated in theatre if they are
female
under the age of 5
white
living in a more deprived area
They are also more likely to have a manipulation in theatre if they attended
an urgent treatment centre
on a weekend
at nighttime
in the summer
Those attending in more recent years were less likely to have their fracture manipulated in theatre, further indicating there has been a move towards manipulating more fractures in the emergency department.
Over the last 5 years
No change in the proportion of fractures being x-rayed.
Slight reduction in the proportion of fractures being followed up, but significant increase in the proportion that are conducted virtually.
The proportion of forearm fractures manipulated in theatre has decreased while the proportion manipulated in the emergency department has increased.
The overall manipulation rate for forearm fractures has reduced over the last 5 years.
Overall, there is a trend towards more conservative management of paediatric fractures.
Percentage of clavicle fractures x-rayed
Min | 5.9 % |
1st quartile | 87.7 % |
Median | 93.2 % |
3rd quartile | 95.7 % |
Max | 100 % |
Reducing the percentage of x-rays to the level of the lowest decile of trusts (77.3%) would give an annual reduction in England of 1,986 (15.5%) x-rays.
Percentage of toe fractures x-rayed
Min | 2.4 % |
1st quartile | 72.6 % |
Median | 82.4 % |
3rd quartile | 89.7 % |
Max | 100 % |
Reducing the percentage of x-rays to the level of the lowest decile of trusts (62.3%) there would give an annual reduction in England of 2,412 (22.5%) x-rays.
Min | 19.8 % |
1st quartile | 56.2 % |
Median | 65.1 % |
3rd quartile | 77.2 % |
Max | 98 % |
Reducing the percentage of follow-ups to the level of the lowest decile of trusts (46%) would give an annual reduction in England of 13,768 (30.7%) follow-up appointments.
Min | 25.9 % |
1st quartile | 74.2 % |
Median | 83.6 % |
3rd quartile | 90.4 % |
Max | 100 % |
Reducing the percentage of follow-ups to the level of the lowest decile of trusts (61.8%) would give an annual reduction in England of 4,486 (25.8%) follow-up appointments.
Min | 5.6 % |
1st quartile | 46.5 % |
Median | 61.2 % |
3rd quartile | 82.2 % |
Max | 97.4 % |
Reducing the percentage of follow-ups to the level of the lowest decile of trusts (31.4%) would give an annual reduction in England of 4,440 (49.9%) follow-up appointments.
Min | 20.2 % |
1st quartile | 72.8 % |
Median | 83.7 % |
3rd quartile | 90.1 % |
Max | 100 % |
Reducing the percentage of follow-ups to the level of the lowest decile of trusts (60%) would give an annual reduction in England of 2,817 (26.4%) follow-up appointments.
Min | 11.1 % |
1st quartile | 31.7 % |
Median | 45.4 % |
3rd quartile | 56.9 % |
Max | 100 % |
Reduced the percentage of follow-ups to the level of the lowest decile of trusts (21.3%) would give an annual reduction in England of 3,260 (53%) follow-up appointments.
Total annual reduction of 28,771 follow-up appointments in England.
This may be an underestimation as number of children may have more than one follow-up appointment that could be deemed unnecessary.
This includes all outpatient attendances, including physiotherapy appointments, in the 3 months post-fracture.
There is significant variability between trusts in the number of follow-up appointments for clavicle fractures.
Many clavicle fractures should not require follow-up yet some trusts are averaging 2-3 follow-up appointments per clavicle fracture, indicating a potential to further decrease follow-up appointments if second and subsequent appointments are considered.
Min | 0.2 % |
1st quartile | 2.3 % |
Median | 4.4 % |
3rd quartile | 6.5 % |
Max | 21.4 % |
There could be an annual reduction in England of 1,747 (54.5 %) manipulations in theatre, if all trusts reduced their percentage to the level of the lowest quartile (2.3%).
NOTE: Very low numbers at many providers
Min | 0 % |
1st quartile | 0.5 % |
Median | 1.3 % |
3rd quartile | 2 % |
Max | 8.8 % |
There could be an annual reduction in England of 177 (67%) manipulations in theatre, if all trusts reduced their percentage to the level of the lowest quartile (0.5%).
Clavicle | Elbow | Forearm | Tibia/Fibula | Toe | Total | |
|---|---|---|---|---|---|---|
Reduction in x-rays in emergency care | 1,986 (15.5%) | - | - | - | 2,412 (22.5%) | 4,398 (18.7%) |
Reduction in follow-up appts | 4,440 (49.9%) | 4,486 (25.8%) | 13,768 (30.7%) | 2,817 (26.4%) | 3,260 (53%) | 28,771 (32.7%) |
Reduction in manipulations in theatre | - | 177 (67%) | 1,747 (54.5%) | - | - | 1,924 (55.4%) |
Scope to reduce x-rays for clavicle and toe fractures in England by almost a fifth.
Scope to reduce follow-up appointments for elbow, forearm, clavicle, tibia/fibula and toes fractures in England by a third.
While nationally manipulations in theatre have decreased in recent years, at some trusts there is still scope to reduce the proportion of forearm and elbow fractures manipulated in theatre. This could further half the number of elbow and forearm manipulations performed in theatre in England.
There are some significant differences between the data included by GIRFT/Model Hospital and the data used in this study. Our analysis:
excluded certain fracture types, e.g open fractures which are assumed to all require treatment in theatre.
excluded any activity coded as re-manipulations.
used only the most recent year where follow-up data is available (2022/23)
links emergency care data to inpatient data and so we are only considering manipulations in theatre for patients identified in the emergency care dataset as having a fracture.
GIRFT metric does not account for any regional differences in fractures rates, but it is unaffected by the poor recording of diagnoses codes in emergency care.
Our measure accounts for regional differences, but does rely on the assumption that the fractures requiring interventions and those that do not are equally likely have a diagnosis code recorded in emergency care.
Graphs show our data for the number of forearm fractures manipulated in theatre in 2022/2023 (identified by linking to emergency care fracture records), but use different denominators to calculate the rate.
Top figure shows the 20 trusts with the highest (red) and 20 trusts with the lowest (green) rates of manipulations in theatre using total A&E attendances as the denominator.
Bottom figure uses the number of A&E attendances for forearm fractures as the denominator, and the same trusts labelled above are shown in their new positions according to this new metric.
Example 1, using total A&E attendances as the denominator The Royal Cornwall Hospitals Trust has the 11th highest rate of forearm manipulation in theatre in England. Using the number of forearm fractures as the denominator the manipulation rate moves The Royal Cornwall Hospitals Trust out of the highest quartile down to 43rd highest.
Example 2, using total A&E attendances as the denominator Chelsea and Westminster Hospital NHS Foundation trust has the 16th lowest rate in England. However, when the number of forearm fractures is used as the denominator the trust doesn’t actually perform as well as first thought, moving to the 42nd highest, with a similar rate to The Royal Cornwall Hospitals Trust.
It is possible some of our numbers may be underestimates due to some issues with coding/reporting especially as diagnoses codes are not always recorded in the emergency care dataset. For example the number of manipulations of elbow fractures in theatre is considered low, this may be a coding issue or related to the inability from the coding to determine which radial fractures should be classed as elbow rather than forearm fractures.
Our incidence rates are for closed fractures only, open fractures, pathological fractures and birth trauma fractures were excluded.
Coding of fractures is not specific enough to determine at an individual level which fractures could be managed more conservatively, so we are relying on comparing proportion between trusts. Some fractures will be more complex and require manipulation and follow-up, but we can’t be sure whether all trusts have a similar proportion of more complex fractures.
Only closed manipulations without internal fixation are included in our data, so if some trusts are treating a higher proportion of fractures with internal fixation then their rate of closed manipulations could appear lower. We have also not included re-manipulations in our data.
There will be a small number of cases where a child has more than one fracture or other injuries.
It should be noted is that data is allocated to the trust where the child attended the emergency department, but where they were followed-up if that is different